HomeMy WebLinkAboutBuilding Permit #169-11 - 14 WALNUT AVENUE 8/25/2010 BUILDING-PERMIT of 00RD ^!
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TOWN OF NORTH ANDOVER �� 4``.:[tr 6
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APPLICATION FOR PLAN EXAMINATION _<.•- '
Permit NO;10_ L(_ Date Received
Date Issued:
�9SSACHLI`S���� .
IMPORTANT:Applicant must complete all items on this
page
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TYPE
IMPROVEMENT"
EMENT PROPOSED USE
Reside ial Non- Residential
New Building ne family
Addition Two or more family Industrial
Alteratio No. of units: Commercial
epair, replacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION WORK TO BE PREFO ED:
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Identification PIease Type or Print Clearly)
OWNER: Namephone 7� 57
Address:
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ARCHITECT/ENGINEER `� Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ � 77 QQ FEE:
Check No.: (c� 23 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acc ss to the, aranty^fun
, rte:��� e _ • {._.:- _
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools "
Well Tobacco Sales Food Packaging/Sales`
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM _
- : tet. ..•
DATE REJECTED DATE APPROVED'
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
C OEvi viEN T S
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
_ - _
. 'x:21 .,-r�.. _-•t` _
; YR wDE ?F ► IETx'T::The _Drn
Located_ > �4Ylai,.Streef.a -F
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MiUI. _:S
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A
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
f
❑ Notified for pickup - Date
Doc.BuiIding Permit Revised 2010
Building Department
The following is'a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, interior Rehabilitation Permits
❑ Building PP Permit Application
I,
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or..Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculationslicable If Applicable)
PP ) �
❑ Mass check.Energy Compliance Report (if Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
. 9
.-.-New Construction (Single and Two Family) '
❑ Building Permit Application
❑ ^eii.1ied Proposed Plot Plan.
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic clic Calculations (If Applicable)
)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2008
7
Location
aoq!?�
AhNo. / Date
NOR, TOWN OF NORTH ANDOVER
3? °', - -.,• OCL° ; ; Certificate of Occupancy $
b'••�°'�t�' Building/Frame Permit Fee $J,�cMusE �
Foundation Permit Fee $
Other Permit Fee $
i
TOTAL $
Check #
233b,."
Building Inspector
The C'ommonwe¢ith of Alassachusetts
Department o f Industrial Accidents
Office of Investigations
600 Washinbaton Street
.Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plum
At7plicant Infortrcation hers
Please Print Legibly
Name (Business/OrganizatiotrMdividual): j s
010 Ai�O�
Address;
City/State/zip:
vX Fo CSI,¢D 1 gz 1
Phone#:�g 8��'-2 a-71
Are you an employer? Check the appropriate boa;
1.❑ I am a employer with 4. ❑ I am a---neral contractor and I Type of project(required):
2.Remployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
l am a sole proprietor or partner_ listed on the attached sheet 1 ?• r-
ship and have no employees These sub- �J modeling
working for me i� any capacity. workers, contractors have 8. Demolition
ors comp.insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
3•❑ r'e'quired] officers have exercised their 10 ❑Electrical repairs or additions
I am a homeowner doing all work right of examption Per MGL 11.❑Plumbing repairs or
myself. [No workers'comp. c. 152 eP additions
insurance required.] t §1(4),and we have no
q ] employees. [No workers' 17•❑Roof repairs
comp.insuraUce required.] 13•❑ Other
k= } Iicaa±t5at checks bo::.�ii st;Lsq_ o�!
aectr C_iCA'8.^.CY,^.^.a�••^.-^.:A�014-3 CCrnr,,,,���*:C�....r:....
t I�omeowness who submit this affidavit inditiag the}'ire do E at wcre ad+Contractors that check t`�is bo.*.must arched an additional sheet showing outside cont*acte 4;i,. submit a new amdavit indicating such.
o the came of the sub contractors and their workers'comp povcy information.
I am an employer that is providing workers'compensation insurance for rely employees Below,i
f° On' s the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Sob Site Address:
Attach a copy of the workers' compensation policy declaration pace(showing the
pol crp.
Failure to secure coverage as required under Section 25A of MGL wing Policy nnmber•and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as Glc. 152 can lead to the imposition of criminal penalties of a
of up to $250.00 a day against the violator. Be advised that a co penalties in the fog of a STOP WORK ORDS a fine
Investigations of the DIA for insurance coverage verification Py of stat,^ment may be forwarded to the Office of
I do hereby certify under the pains
p realties of periu?y th4rr the informatiM7 provided above is true and correct
Signature:
r
Phone#: a�
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building.Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbin�
6. Other b Inspector
Contact Iverson:
"hone.
Information an_ d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every pc---non in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association Dx-other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartmL ent s and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintemmce,construction or repair work on suchdwelling house
or on the grounds or building appurtenant thereto shall not be:cause of such,employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of c03Mpliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)stages"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work im-V-U acceptable evidence of compliance with the insurame
requirements of this chapter have been presented to the comacting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s) name(s), address(es) and phone number(s)along with their certificate(s)of .
insurance. Limited Liability Companies(LLC) or Limited Liabfiity partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' comp enation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of ink mce coverage. .Also be sl re to sign and date the affidavit. The affidavit should
be rctarned to the city or toLTi ha'i the application for the TerLxltt'or license LS being requested,not the
.lepartn ent of
Industrial Accidents. Should von have any questions regardin—b the law or if you are:...i;ired to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. 'Ile Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition.an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future perxnits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,.telephone.and.fax.number....
The Commonwealtlz Gf Mas�usetts.
Departmem of Industrial Accidents
Office of LaN estiaations
600 Watckn Street
Boston,MA 0.2111
Tel. # 617-72.7-4900 ext 40.6 or 1-8 77-M ASSAFE
Re�,ised f-26-45
Fw, #1617-72.7-7149
utrvrw.mass..gov/dla.
NORTH
TOANM of Andover
-o dover, Mass.,
LAKE
A COCMICMEWICK\y
ORATED PPa��S
BOARD OF HEALTH
Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.............. .�J.V. I.......... .±......!.0.... ..................................................................... Foundation
has permission to erect........................................ buildings on .. ` ! V ' Rough-
to be occupied as �w�-........� 44�.�- pp,4c liJ 1l�lG�C7 Chimney
�R•....
.. . . . . . . . ..............................................
provided that the erson ace tin this permit shall in eve res ect confor to the terms of the application on file in
P P P 9 P �l PP � Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough
Final
�-� PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTR N ARTS Rough
...... ....... ..................................................................................... .........
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
tA.
{OME IMPROVEMENT CONTRACTOR
Regilstration 117187_
Expiraflor% 9/6/2010 Tr# 273954.
"e "Type:_DBA
DAVIS CONST
WILLIAM DAVIS,;R
6811 4AI N ST
h-,)XFORD, MSA Ci 921 Administrator,
' itSti;lCflUSc[tti- 7
Board Bc
of Pallment or PubBuildin"Rcl ulatitic Safctr
ons ani Standard,,,
Construction Supervisor Licens
License: CS 57105 e C
Restricted to: 00 -
WILLIAM J DAVIS JR
68 MAIN ST
BOXFORD, '
MA 01921 �
C"°1tD1ssil'ner Expiration: 12/1/2011'
Tr#: 10941
'h h1
t .
DAVIS WOODWORKING
68 Main Street • Boxford,Ma.01921 • Tel 978-887-0282
CONTRACT PROPOSAL
To: 7/8/10
Steve Anthony MA CS #57105
14 Walnut Skeet i'E. Home Improvement#117187
N6 /pbgVAhkwd, MA. 01810 Fully Insured
978-853-3908
For: Replacement of picture window as follows:
1) Remove existing glass window. Build up wall area to accept 400 series Anderson
Model 45C.14-20 Bay window unit; rough opening to be K-D spruce framing, 1/2 CLX
fir plywood; exterior to be Typar house wrap, clear primed finger jointed red cedar
clap boards w/stainless steel ring nails applied at staggered joints to blend
appearance; interior to be insulated with kraft paper vapor barrier and 1 x8 v-groove
T&G pine wainscot to match existing wall detail.
2) Bay window roof to match existing fiberglass asphalt shingles. Support to be two pine
brackets to match existing.
3) All exterior seams to be caulked with pro-flex paintable silicone flexible caulking. All
painting to be done by the owner.
4) Any unforeseen structural repair work will be done properly as necessary at an
additional cost to be determined at the time of discovery.
5) Work to begin on or before July 19, 2010 and to be completed by July 26, 2010,
5� weather permitting. 6 Zfl7, az) S
Total cost of project is $ fi,3-67 0. Payments be made as follows:
$ 3,083.50 (1/2) deposit to be paid at the acceptance of proposal,
i cfF,� $ 3,083.50 (1/2) to be paid at the completion of the project.
Acceptance of proposal:
Signed
/jJ� Date 7A//
Date-
7 �l1b
Signed —
9